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PROBLEMS_in_Empty_C-CDA_2.1 (C-CDAR2.1).xml
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PROBLEMS_in_Empty_C-CDA_2.1 (C-CDAR2.1).xml
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<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
Title: Continuity of Care Document (CCD)
This file was based on MU testing file named: 170.315_b1_toc_gold_sample2_v2.xml
All component/section wihtin structuredBody have been emptied to provide a template for testing specific entries
********************************************************
Disclaimer: This sample file contains representative data elements to represent a Continuity of Care Document (CCD).
The file depicts a fictional character's health data. Any resemblance to a real person is coincidental.
To illustrate as many data elements as possible, the clinical scenario may not be plausible.
The data in this sample file is not intended to represent real patients, people or clinical events.
This sample is designed to be used in conjunction with the C-CDA Clinical Notes Implementation Guide.
********************************************************
-->
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="C:\XML\CDA_SDTC_Schema\infrastructure\cda\CDA_SDTC.xsd"
xmlns:voc="urn:hl7-org:v3/voc" xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<!-- US Realm Header ID-->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- CCD template ID-->
<templateId root="2.16.840.1.113883.10.20.22.1.2" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<!-- Globally unique identifier for the document -->
<id extension="TT662" root="2.16.840.1.113883.19.5.99999.1"/>
<code code="34133-9" displayName="Summary of episode note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<!-- Title of this document -->
<title>170.315_b1_toc_gold_sample2 test data</title>
<effectiveTime value="201507221800-0500" />
<confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality"/>
<languageCode code="en-US"/>
<setId extension="sTT662" root="2.16.840.1.113883.19.5.99999.19"/>
<!-- Version of this document -->
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id extension="414122222" root="2.16.840.1.113883.4.1"/>
<!-- Example Social Security Number using the actual SSN OID. -->
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-777-1234" use="MC"/>
<telecom value="tel:+1(555)-723-1544" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<given>Richard</given>
<family>Maur</family>
<suffix>jr</suffix>
</name>
<administrativeGenderCode code="M" displayName="Male" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<!-- Date of birth need only be precise to the day -->
<birthTime value="19800801"/>
<maritalStatusCode nullFlavor="NI"/>
<religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystem="2.16.840.1.113883.5.1076" codeSystemName="HL7 Religious Affiliation"/>
<raceCode nullFlavor="UNK"/>
<sdtc:raceCode nullFlavor="UNK"/>
<ethnicGroupCode nullFlavor="UNK"/>
<languageCommunication>
<languageCode code="en"/>
<modeCode code="ESP" displayName="Expressed spoken"
codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel:+1(555)-555-5000"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<!-- The author represents the person who provides the content in the document -->
<author>
<time value="20150722"/>
<assignedAuthor>
<id extension="111111" root="2.16.840.1.113883.4.6"/>
<code code="281P00000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Hospitals; Chronic Disease Hospital"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- The dataEnterer transferred the content created by the author into the document -->
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Mary</given>
<family>McDonald</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<!-- The informant represents any sources of information for document content -->
<informant>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<informant>
<relatedEntity classCode="PRS">
<!-- classCode PRS represents a person with personal relationship with the patient. -->
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<relatedPerson>
<name>
<given>Caroline</given>
<family>Maur</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<!-- The custodian represents the organization charged with maintaining the original source document -->
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99998899" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel:+1(555)-555-5000"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<!-- The informationRecipient represents the intended recipient of the document -->
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<!-- The legalAuthenticator represents the individual who is responsible for the document -->
<legalAuthenticator>
<time value="20150722"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999998899" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<!-- The authenticator represents the individual attesting to the accuracy of information in the document-->
<authenticator>
<time value="20150722"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999998899" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<!-- The participant represents supporting entities -->
<participant typeCode="IND">
<!-- patient's grandfather -->
<associatedEntity classCode="PRS">
<code code="GPARNT" displayName="grandparent" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-723-1544" use="HP"/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Issac</given>
<family>Maur</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<!-- Note: Entities playing multiple roles are recorded in multiple participants -->
<participant typeCode="IND">
<!-- patient's spouse -->
<associatedEntity classCode="PRS">
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-723-1544" use="HP"/>
<associatedPerson>
<name>
<prefix>Ms</prefix>
<given>Caroline</given>
<family>Maur</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<code code="423123007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"
displayName="Burn caused by fire"/>
<effectiveTime>
<low value="201507221800-0500"/>
<high value="20150722230000-5000"/>
</effectiveTime>
<!-- since there are two Care Team members we need two performer elements. -db -->
<!-- Note: example of Care Team here:
https://github.com/gecole/HL7-Task-Force-Examples/blob/master/CareTeamToC170.314b2Ambulatory.xml
db -->
<performer typeCode="PRF">
<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction" displayName="primary care physician">
<originalText>Primary Care Provider</originalText>
</functionCode>
<assignedEntity>
<id extension="5555555555" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" displayName="Allopathic & Osteopathic Physicians; Family Medicine, Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix qualifier="TITLE">Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id extension="99998899" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel:+1(555)-555-5000"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PRF">
<!-- we do not have a function code for this person since recording as RN for now -->
<time>
<low nullFlavor="UNK"/>
</time>
<assignedEntity>
<!-- this provider has an id, but it is not an NPI -->
<id extension="91138" root="1.3.6.1.4.1.22812.4.99930.4"/>
<!-- the provider is a Registered Nurse - may not be so -->
<!-- note: we don't know what Mary is from the test data
but since not specified, RN should not be an issue -db -->
<code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" code="163W00000X" displayName="Nursing Service Providers; Registered Nurse"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Mary</given>
<family>McDonald</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- added componentOf to represent encounter and to represent length of stay better as per SME suggestion -db -->
<componentOf>
<encompassingEncounter>
<id extension="9937012" root="2.16.840.1.113883.19"/>
<effectiveTime>
<!-- represents length of time spent in hospital -db -->
<low value="201507221800-0500"/>
<high value="20150722230000-5000"/>
</effectiveTime>
</encompassingEncounter>
</componentOf>
<!-- ******************************************************** CDA Body ******************************************************** -->
<component>
<structuredBody>
<!-- ***************** ALLERGIES *************** -->
<!-- No known allergies -->
<component>
<section>
<!-- *** Allergies and Intolerances Section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Alerts section template -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>ALLERGIES AND ADVERSE REACTIONS</title>
<text>No Known Drug Allergies</text>
<!-- replaced Allergy Problem Act (R1.1) with
Allergy Concern Act (V3) to meet R2.1 validation requirements -DB-->
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<!-- ** Allergy Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
<!--Critical Change-->
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b15-11db-9fe1-0831200c9a66"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<!-- The statusCode represents the need to continue tracking the allergy -->
<!-- This is of ongoing concern to the provider -->
<statusCode code="active"/>
<effectiveTime>
<!-- The low value represents when the allergy was first recorded in the patient's chart -->
<low value="20150722"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<!-- using negationInd="true" to signify that there are is NO food allergy (disorder) allergy -db -->
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<!-- ** Allergy observation (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b16-11db-9fe1-0832200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NA"/>
<!-- using Drug allergy (disorder) along with negationInd instead -db -->
<value xsi:type="CD" code="416098002"
displayName="Allergy to drug (finding)"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT">
</value>
<!-- In C-CDA R2 the participant is required. The SNOMED code ="105590001" displayName="Substance" could be used in the participant-->
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code nullFlavor="NA"/>
</playingEntity>
</participantRole>
</participant>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- ******************************* MEDICATIONS ***************************** -->
<!-- No known medications -->
<component>
<section>
<!-- *** Medications Section (entries required) (V2) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
<title>MEDICATIONS</title>
<text>No known Medications</text>
<entry>
<!-- Act.actionNegationInd -->
<substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="true">
<!-- ** Medication Activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0833200c9a66"/>
<statusCode code="active"/>
<effectiveTime nullFlavor="NA"/>
<doseQuantity nullFlavor="NA"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code nullFlavor="OTH" codeSystem="2.16.840.1.113883.6.88">
<translation code="410942007" displayName="drug or medication"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!-- ******************************* MEDICATIONS ADMINISTERED *****************************
NO known medications
-->
<component>
<section>
<!-- The section contains the medications taken by the patient prior to
and
at the time of admission to the facility. -->
<!-- Admission Medications Section (entries optional) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.44" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.44"/>
<code code="42346-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MEDICATIONS ON ADMISSION"/>
<title>Admission Medications</title>
<text>No Medications Administered</text>
<entry>
<!-- Act.actionNegationInd -->
<substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="true">
<!-- ** Medication Activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0834200c9a66"/>
<statusCode code="active"/>
<effectiveTime nullFlavor="NA"/>
<doseQuantity nullFlavor="NA"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code nullFlavor="OTH" codeSystem="2.16.840.1.113883.6.88">
<translation code="410942007" displayName="drug or medication"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!-- Added Discharge Medications Section (entries required) (V3) No known medications -->
<component>
<section nullFlavor="NI">
<!-- Discharge Medications Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.11.1" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.2.11.1" />
<code code="10183-2" displayName="Hospital Discharge Medications"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC">
<translation code="75311-1" displayName="Discharge Medications"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
</code>
<title>Discharge Medications</title>
<text>No Information</text>
</section>
</component>
<!-- ***************** PROBLEM LIST *********************** -->
<!-- Problem examples -->
<component>
<!-- An example of how to use a qualifier. This example shows presence of a problem/value/translation, although it could also be used to refine the problem/value -->
<!-- The use of qualifiers could also be used on other sections, such as qualifying a procedure -->
<!-- An example of how to use a qualifier. This example shows presence of a problem/value/translation, although it could also be used to refine the problem/value -->
<!-- The use of qualifiers could also be used on other sections, such as qualifying a procedure -->
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/>
<title>Problem List</title>
<text>
<table>
<thead>
<tr>
<th>Name</th>
<th>Dates</th>
<th>Location/Qualifier</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr ID="Problem14">
<td ID="ProblemDescription14">Below Knee Amputation</td>
<td>
<content>Onset: Apr 2 2014</content>
</td>
<td>Left</td>
<td>Active</td>
</tr>
<tr ID="Problem1">
<td ID="Problem1Value">Community Acquired Pneumonia</td>
<td>Onset: February 27 2014</td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
<id root="e5fbc288-659f-4aeb-a5e1-eb7cc8fcdfaf" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" />
<!-- While clinicians can track resolved problems, generally active problems will have active concern status and resolved concerns will be completed -->
<statusCode code="active" />
<effectiveTime>
<!-- This represents the time that the clinician began tracking the concern. This may frequently be an EHR timestamp-->
<low value="20140403124536-0500" />
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<id root="ac416033-3cc1-4485-ab31-36ce7669f55c" />
<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="55607006" displayName="Problem">
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>
</code>
<text>
<reference value="#Problem14" />
</text>
<statusCode code="completed" />
<effectiveTime>
<!-- This represents the date of biological onset. This can be before the patient vistited the clinician, as illustrated in this example-->
<low value="20140402" />
</effectiveTime>
<!-- This is a SNOMED code as the primary vocabulary for problem lists. It would be preferable to have a SNOMED code but no direct translation is available here. -->
<value xsi:type="CD" nullFlavor="OTH">
<originalText>
<reference value="#ProblemDescription14" />
</originalText>
<translation xsi:type="CD" code="V49.75" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9" displayName="Below Knee Amputation Status" />
</value>
<targetSiteCode xsi:type="CD" code="30021000" codeSystem="2.16.840.1.113883.6.96" displayName="Structure of lower extremity from knee to ankle">
<!-- This is an example of a qualifer which would affect a quality measure (e.g. cms 123 Diabetes Foot Exam) -->
<!-- a qualifier may be a child element to <value> or <translation>. Here we use translation since it refines an ICD-9 code-->
<qualifier>
<name code="272741003" codeSystem="2.16.840.1.113883.6.96" displayName="Laterality" />
<value code="7771000" codeSystem="2.16.840.1.113883.6.96" displayName="Left"/>
</qualifier>
</targetSiteCode>
</observation>
</entryRelationship>
</act>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
<!-- Since this represents an element which has been imported from the original document
but may vary from original act, a different GUID is used to idenitfy -->
<id root="11526f79-94a3-4682-a969-0f3d039db732"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20140302124536-0500"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4" />
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<!-- Since this represents an element which has been imported from the original document
but may vary from original observation, a different GUID is used to idenitfy -->
<id root="35e97377-b63b-4e6a-a53e-9cfb016bea0b"/>
<code code="55607006" displayName="Problem"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Problem"/>
</code>
<text>
<reference value="#Problem1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20140227"/>
</effectiveTime>
<value xsi:type="CD" code="385093006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Community acquired pneumonia">
<originalText>
<reference value="#Problem1Value" />
</originalText>
</value>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20140302124536"/>
<assignedAuthor>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101"
codeSystemName="NUCC" displayName="Allopathic & Osteopathic Physicians; Internal Medicine, Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- This reference refers to the external document where the problem was documented -->
<!-- It uses a template for externalDocument from the QRDA 1 3.1 Implementation Guide-->
<reference typeCode="REFR">
<externalDocument classCode="DOCCLIN" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.115" extension="2014-06-09" />
<!-- This refers to the ClinicalDocument/id of the original document -->
<id extension="TT661" root="2.16.840.1.113883.19.5.99999.1"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summary of episode note" />
<!-- While not required, there is a benefit of using <setId> and <versionNumber> as a secondary key on documents.
If the flow from a document source system or repository to a destination system is infrequent or not able to guarantee
sequential transmission of document revisions. The setId and versionNumber pair are actually better for detecting which
new document revises a previous older version of that document. -->
<!-- If setId and versionNumber are not available or applicable, they may be omitted -->
<setId root="004bb033-b948-4f4c-b5bf-a8dbd7d8dd40"/>
<versionNumber value="1"/>
</externalDocument>
</reference>
<!-- This reference refers to the observation within external document the where the problem was documented -->
<!-- Other options are the use of reference/externalAct or reference/externalProcedures -->
<reference typeCode="REFR">
<externalObservation classCode="OBS" moodCode="EVN">
<!-- This refers to the observation/id of the original observation -->
<id extension="10241104348" root="1.3.6.1.4.1.22812.4.111.0.4.1.2.1"/>
<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>
</code>
</externalObservation>
</reference>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- ************************ ENCOUNTERS *********************** -->
<!-- No known encounters -->
<component>
<section nullFlavor="NI">
<!-- *** Encounters section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
<title>ENCOUNTERS</title>
<text>No Encounters</text>
</section>
</component>
<!-- ************** PROCEDURES ***************** -->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<!-- (NO) UDI section based off of https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Implanted_Devices.xml
-db -->
<!-- ************** PROCEDURES and UDI ***************** -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.7" extension="2014-06-09" />
<!-- Procedures section template -->
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURES" />
<title>Procedures</title>
<text>No Information</text>
</section>
</component>
<!-- ************** No UDI ***************** -->
<component>
<section>
<!-- Medical equipment section -->
<templateId root="2.16.840.1.113883.10.20.22.2.23" extension="2014-06-09"/>
<code code="46264-8" codeSystem="2.16.840.1.113883.6.1" />
<title>MEDICAL EQUIPMENT</title>
<!-- Alternative text: Patient has no history of procedures with implantable devices'-->
<!-- Alternative text: Patient has no implanted devices'-->
<text>
<paragraph ID="Proc2">Patient has no history of implantable devices</paragraph>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN" negationInd="true">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="d5b614bd-01ce-410d-8728-e1fd01dcc72a" />
<code code="71388002" codeSystem="2.16.840.1.113883.6.96"
displayName="Procedure"/>
<text>
<reference value="#Proc2"/>
</text>
<statusCode code="completed" />
<effectiveTime nullFlavor="NA" />
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<!-- UDI is 'not applicable' since no procedure -->
<id nullFlavor="NA" root="2.16.840.1.113883.3.3719"/>
<playingDevice>
<code code="40388003" codeSystem="2.16.840.1.113883.6.96"
displayName="Implant"/>
</playingDevice>
<scopingEntity>
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
</section>
</component>
<!-- ******************** IMMUNIZATIONS ********************* -->
<!-- No immunizations -->
<component>
<section>
<!-- *** Immunizations Section (entries required) (V2) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
<title>IMMUNIZATIONS</title>
<text>No immunization history</text>
<entry typeCode="DRIV">
<!-- using negationInd="true" to signify that there are no known immunizations -->
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="true">
<!-- ** Immunization Activity (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.52" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.52"/>
<id root="de10790f-1496-4729-8fe6-f1b87b6219f7"/>
<statusCode code="active"/>
<effectiveTime nullFlavor="NA"/>
<routeCode nullFlavor="NA"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Immunization Medication Information (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.54" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.54"/>
<manufacturedMaterial>
<!-- there is no generic vaccine code and no known recommended way to do this -
leaving generic flu for now just as an example. Not sure if it makes more sense to apply a nullFlavor? -db -->
<code nullFlavor="OTH">
<!-- Optional original text -->
<originalText>Vaccination</originalText>
<translation code="71181003" displayName="vaccine"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</code>
<!-- NA since there is no immunization data -db -->
<lotNumberText nullFlavor="NA"/>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!-- ************* VITAL SIGNS *************** -->
<!-- No vital signs -db -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01" />
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs" />
<title>VITAL SIGNS</title>
<text>No Recorded Vital Signs</text>
</section>
</component>
<!-- ******************* SOCIAL HISTORY ********************* -->
<!-- edited as per test doc - most of this data is directly relevant -db -->
<component>
<section>
<!-- ** Social History Section (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Social History Observation</th>
<th>Description</th>
<th>Dates Observed</th>
</tr>
</thead>
<tbody>
<tr>
<td>Current Smoking Status</td>
<td>Current every day</td>
<td>July 22, 2015</td>
</tr>
<tr>
<td ID="BirthSexInfo">Birth Sex</td>
<td>Male</td>
<td>July 22, 2015</td>
</tr>
</tbody>
</table>
</text>
<!-- Current Smoking Status - July 22, 2015 -db -->
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Smoking Status - Meaningful Use (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.78" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<id extension="123456789" root="2.16.840.1.113883.19"/>
<!-- code SHALL be 72166-2 for Smoking Status - Meaningful Use (V2) -db -->
<code code="72166-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Tobacco smoking status NHIS"/>
<statusCode code="completed"/>
<!-- The effectiveTime reflects when the current smoking status was observed. -->
<effectiveTime value="20150722"/>
<!-- The value represents the patient's smoking status currently observed. -->
<!-- Consol Smoking Status Meaningful Use2 SHALL contain exactly one [1..1] value (CONF:1098-14810), which SHALL be selected from ValueSet Current Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2014-09-01 (CONF:1098-14817) -db -->
<value xsi:type="CD" code="449868002" displayName="Smokes tobacco daily" codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entry>
<!-- removed Social history observation (V3) entry for "Alcoholic drinks per day" -db -->
<!-- Add Birth Sex entry -->
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.200" extension="2016-06-01"/>
<code code="76689-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Sex Assigned At Birth"/>
<text>
<reference value="#BirthSexInfo"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20150722"/>
<value code="M" codeSystem="2.16.840.1.113883.5.1" xsi:type="CD" displayName="Male"/>
</observation>
</entry>
</section>
</component>
<!-- ******************** RESULTS ************************ -->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<component>
<section nullFlavor="NI">
<!-- Results Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RESULTS"/>
<title>RESULTS</title>
<text>Laboratory Test: None needed. Laboratory Values/Results: No Lab Result data</text>
</section>
</component>
<!-- removed component Advance Directives as not required by test data -db -->
<!-- removed component Family History as not required by test data -db -->
<!-- removed component Functional Status as not required by test data (specific to 170.315(b)(1), (b)(2)) -db -->
<!-- removed component Medical Equipment as not required by test data -db -->
<!-- removed component Payers as not required by test data -db -->
<!-- added Assessment -db -->
<!--
********************************************************
Assessment
********************************************************
-->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<component>
<section nullFlavor="NI">
<!-- Assessment Section -db -->
<!-- There is no R2.1 (or 2.0) version of Assessment Section, using R1.1 templateId only -db -->
<templateId root="2.16.840.1.113883.10.20.22.2.8"/>
<code codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" code="51848-0"
displayName="Evaluation note"/>
<title>ASSESSMENTS</title>
<text>No assessment information</text>
</section>
</component>
<!-- ******************* PLAN OF TREATMENT ********************** -->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<component>
<section>
<!-- **** Plan of Treatment Section (V2) **** -->
<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of care note"/>
<title>TREATMENT PLAN</title>
<text>
No Plan of treatment
</text>
</section>
</component>
<!-- Added Goals - original version from C-CDA_R2_Care_Plan.xml from R2.0 IG package.
There are no duplicated template Ids with extensions -
as there is only one version in existence for each section and entry listed -db -->
<!--
********************************************************
Goals
********************************************************
-->
<!-- edited as per test doc -db -->
<component>
<section nullFlavor="NI">
<!-- Goals Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.60"/>
<code code="61146-7" displayName="Goals" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Goals Section</title>
<text>No goal information</text>
</section>
</component>